Provider Demographics
NPI:1720031511
Name:THACKER, IKE CLAYTON (MD)
Entity Type:Individual
Prefix:
First Name:IKE
Middle Name:CLAYTON
Last Name:THACKER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:712 N WASHINGTON AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75246-1619
Mailing Address - Country:US
Mailing Address - Phone:214-826-8822
Mailing Address - Fax:214-826-9792
Practice Address - Street 1:3500 GASTON AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75246
Practice Address - Country:US
Practice Address - Phone:214-826-8822
Practice Address - Fax:214-926-9792
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2012-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL72152085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX161586601Medicaid
TX159116603Medicaid
TX159116604Medicaid
TX8A9173Medicare PIN
TX8A9284Medicare PIN
TXP00091309Medicare PIN
G54985Medicare UPIN
TX159116604Medicaid
TX159116603Medicaid
TXP00063232Medicare PIN